Obamacare: Health insurance isn't health care

Oct. 27, 2013

Updated 7:44 a.m.

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Whatever effect Obamacare has on access to health insurance, there's no guarantee it will improve health. Experts say those who regularly exercise, such as these people sprinting toward the Newport Beach surf for 1,000-meter ocean swim earlier this year, have the best health propsects. JOSHUA SUDOCK, ORANGE COUNTY REGISTER

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Reducing smoking and exposure to second-hand smoke are among the initiatives of The Public Health Institute. In this 2010 file photo, Ian Zamora holds his cigarette at the wall separating the parking area from the sand at Surfrider Beach in Malibu. FILE: THE ASSOCIATED PRESS

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Where you live often is a better predictor of your health than whether you have insurance. San Bernardino County, where this couple was photographed last year walking past an abandoned store front, is among California's least healthy counties. Orange County, which is far wealthier, is also healthier. FILE: THE ASSOCIATED PRESS

Whatever effect Obamacare has on access to health insurance, there's no guarantee it will improve health. Experts say those who regularly exercise, such as these people sprinting toward the Newport Beach surf for 1,000-meter ocean swim earlier this year, have the best health propsects. JOSHUA SUDOCK, ORANGE COUNTY REGISTER

WHY IT MATTERS

The fight over the Affordable Care Act is missing a crucial point. Health is affected far more by income, education and conditions under which we live than by access to insurance and doctors. Obamacare will hardly touch those things.

DID YOU KNOW?

A little-known part of the Affordable Care Act gives "community transformation grants" to local governments and community organizations to change conditions that contribute to poor health. Several California communities were among the first to benefit from these grants:

• San Diego's "Live Well" program teaches chronically ill patients to play an active role in their care after discharge from the hospital. In the first 10 months of the program, only 2.3 percent of patients involved in the program were readmitted to the hospital within 30 days. The readmission rate was 12.6 percent for patients who were not part of the program.

• In Sacramento County, a "health scan" identified three communities that suffered from high rates of infant mortality, premature death, obesity, tobacco use, diabetes, heart disease and mental illness. A follow-up project established specific goals and charted strategies for reducing these problems in the affected neighborhoods.

• The Public Health Institute is working with 42 rural counties to reduce exposure to second-hand smoke, improve management of chronic disease, build safer routes to school and reduce consumption of sugary beverages. The project is making healthier drinks more accessible in schools, community organizations and government meetings.

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Supporters of the Affordable Care Act say the controversial law is the country's best hope for improving the health of all Americans and slowing the growth in health care costs. Opponents say it will do the opposite: driving up the cost of care, disrupting relationships with our doctors, and making Americans more dependent on government.

But what neither side acknowledges is that, even if the law works exactly as intended, it is unlikely to have much effect on how healthy we are, how sick we get and how long we live.

The Affordable Care Act, at bottom, is more about health insurance than health care. And even the parts about health care are not necessarily about health.

That's because while nearly everyone would like to have access to health care at a reasonable cost, it has become increasingly clear that our health is shaped by forces far greater than our ability to see a doctor or afford a stay in the hospital.

Wealth and poverty, education levels, the environment and stress play a greater role in how long we live than does the medical industry, for all the billions of dollars we spend on it.

LIFE IN A ZIP CODE

Your ZIP code, in fact, tells you more about your life expectancy than your health insurance status.

In Orange County, a baby born today in the poorest part of Santa Ana can expect to live 78 years, on average. A baby born the same day a few miles away in Newport Beach is likely to live a decade longer, 88 years.

A study released this year in Canada provides a clue. That research found that control of Type I diabetes in children was correlated with the income of those children's families – despite access to free health care for all. Controlling the disease requires multiple daily blood tests and insulin injections, and researchers concluded that children in wealthier families were more likely to have the support they needed to keep up with their care.

That's one example, involving one disease. But the same trends can be found again and again.

According to rankings of every county in America by a project of the University of Wisconsin, Orange County is the seventh healthiest in California. Nearby San Bernardino County is the 44th healthiest among the state's 58 counties.

Residents of San Bernardino County are more likely to report having only poor or fair health, more likely to be obese, more likely to have had a preventable stay in the hospital and more likely to die prematurely, before age 75.

THE 'SICK-CARE' SYSTEM

And it is probably no coincidence that residents of Orange County are less likely to live in poverty, more likely to have a high school or college education, have less unemployment, less violent crime, cleaner air, more recreational facilities, better access to healthy foods and less access to fast-food restaurants.

Chet Hewitt, president of the Sierra Health Foundation in Northern California and a big supporter of the Affordable Care Act, says people are going to be disappointed if they expect the federal health overhaul to make the population healthier. He says the law is directed more at what he calls the “sick-care” system – the doctors, hospitals and drugs that we need after something has gone wrong.

“When you think about fixing the sick-care system you are not thinking about health and well-being,” Hewitt said. “If the assumption is that expanding health insurance is going to fix that, I'd call that a lack of informed insight.”

There is one part of the Affordable Care Act that is aimed directly at trying to change the underlying conditions that affect our health. The law sets aside money for “community transformation grants” to local governments and nonprofits to encourage tobacco-free lifestyles, active living and healthy eating, and preventive services aimed at heart disease, diabetes, high blood pressure and other chronic conditions.

The money will go toward making neighborhoods friendlier to pedestrians and bicyclists, improving and expanding parks, protecting safe routes to schools, expanding access to healthy foods and improving preventive care, including the management of chronic disease.

San Diego County has been an aggressive early-adopter of these ideas, and leaders there refer to a threat they call “3-4-50.” Three behaviors (poor diet, lack of physical activity and smoking) contribute to four chronic diseases (heart disease/stroke, cancer, Type II diabetes and lung disease) that cause more than 50 percent of deaths in the region. County residents and the government spend more than $4 billion a year treating these four diseases alone.

In part because of the county's efforts, heart disease and stroke have moved from the leading cause of death from chronic disease to the second-leading cause, and the county recently was found to have the largest reduction in child obesity in Southern California. And a pilot program at a local hospital dramatically reduced the rate of readmissions for chronic disease patients by giving them intensive instruction in how to care for themselves upon leaving the hospsital.

A lot of this might sound simply like common sense, and it is. But the importance of such simple ideas and solutions has been lost amid the controversy over the Affordable Care Act and the fight over how to expand access to insurance, doctors and hospitals.

Maybe, once the dust begins to settle on that fight, we can get back to the more important question: What can we do to improve the health of all Americans?

Contact the writer: Daniel Weintraub has covered California public policy for 25 years. He is editor of the California Health Report at www.healthycal.org

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